Thursday, August 18, 2016

Why is it so Hard for Veterinarians to Say, “I Don’t Know”?

By Marty Becker, DVM
Veterinary Practice News

"Here are 4 tips to help you learn how to say it.


Why is it so hard for us to say, "I don't know"?

As veterinarians, we've studied for 19 years or more. We're highly educated, trained and experienced. We have to make critical calculations for medication dosages, or where and what to cut in surgery. We make life-and-death decisions at least weekly. The pet owner and entire veterinary health care team ultimately look to us, the doctor, for answers.

I routinely hear people saying that in a zombie apocalypse, they'd want to find a DVM rather than an M.D. because we know almost everything about any species. (To us, humans are just another one!) We have the confidence to be an expert on almost everything, including internal medicine, surgery, radiology, pharmacy, dentistry, dermatology, behavior, bereavement counseling and more. We're frequently experts on running a successful small business, including hiring, training and retraining great staff, marketing, motivation, leadership, customer service, inventory control and cash flow.

What we don't have is someone questioning our judgement and pointing out obvious mistakes. In that, we're not alone.

It Happens Everywhere
On Asiana Airlines Flight 214 from Seoul, Korea, to San Francisco International Airport, the Boeing 777 captain was coming in for a morning landing under clear skies. But on this July day in 2013, the pilot brought the plan in too low and too slow, and he hit the seawall short of the runway. He make mistakes, and this was the first fatal crash of a 777 since its 1995 introduction.

The National Transportation Safety Board ruled that the primary cause of the crash were pilot and crew errors. For instance:

  • The pilot unintentionally deactivated the automatic speed control.
  • The flight crew failed to monitor airspeed.
  • Crew members delayed execution of a go-around after they became aware that the airplane was below the acceptable glide path.
  • The flight crew was fatigued, which likely degraded performance.
The flight crew members admitted during interviews that they knew the pilot was making critical errors, but due to rank and culture, they didn't feel they could question authority.

Problems in the Veterinary Practice
Can you see this same type of scenario happening in a veterinary hospital? Of course.

I've written before about having covered up a mistake of mine for over three decades - a mistake that cost a pet's life. We've covered the ground about how the veterinary profession doesn't have transparent body bags. Nobody questions the cause of death in 99.99 percent of animal fatalities, unlike on the human side, where detailed internal reviews and coroner exams are common. In veterinary medicine, it's on us as individuals to admit we made a mistake and take steps to prevent future errors.

Let's focus on what to say and do when you really don't know something, whether it's as simple as the correct drug dosage and best pet food of shampoo, or as complicated as the correct surgical approach during an uncommon surgery. Or coming up with an accurate diagnosis and effective treatment plan on a pet that has seen several vets.

How It Used to Be Done
In my early days of practice in the 1980's, I felt like I was expected to always at least come up with an accurate differential diagnosis, with the assumption that, based on the diagnosis, we'd create an effective treatment plan. In those bad old days - looking back with experienced eyes and a greater understanding of my limitations - there were self-inflicted obstructions to a veterinarian's finding an accurate diagnosis and treatment plan. For example:

  • We didn't talk about cases very much between doctors. Guess it was a case of bravado to go it alone.
  • We didn't ask for advice from or encourage detailed dialogue among the team members as to what might be wrong with a pet and how to fix it. Sure, they might say Fluffy didn't eat or Sparky had diarrhea, but once we were on the road of our diagnosis and treatment plan, nobody dared suggest the driver - the veterinarian - had taken the wrong road.
  • We didn't refer very often.
Our area lacked specialty hospitals in the 1980's, but our Southern Idaho practices were about equidistant from the Washington State University and Colorado State University veterinary colleges.

Looking back, even if a pet continued to worsen the thought was that the treatment wasn't working and that we could make changes, versus we didn't have a clue what's wrong and we need to refer to a team of experts (vet schools) that might crack the code.

The Doctor Is In
I'd been in practice about six years - I'm currently in my 36th year of practice - when a well-known and respected primary care physician from Twin Falls, Idaho, came into my veterinary practice with a very sick retriever.

Dr. Wayne Schow had me as a patient - from mumps to bumps and when I tore my anterior cruciate ligament during eighth-grade football and had a concussion as a senior quarterback. I looked at his dog upside down, inside out and front to back but found very few clues.

Remembering that Dr. Schow always seemed to know what was wrong and how to fix it, he must have sensed my hesitation. "Why don't you run some lab work on him?" he said. "Nobody but God knows everything. The rest of us need help when we don't know."

We ran the tests. The dog had a hollow foreign body that was causing partial obstruction of the bowel. (These were the days before endoscopes.) I never forgot the value in saying. "I don't know, but I'll find out."

4 Tips to Say "I don't know"
In the three decades since that appointment with Dr. Schow, I've embraced "I don't know" and even figured out how to harness and amplify it. Here are my top four steps to knowing how to use "I don't know" to the pet's and your advantage:

  1. Become smarter. By saying you don't know and actually finding the right answer, over the years you actually know more. Just like with my family habit of always looking up words we don't know, I keep digging into a stubborn medical problem until I crack the code. 
  2. T.E.A.M. (Together Each Achieves More). I routinely consult on tough cases with other veterinarians in my practice at North Idaho Animal Hospital, as well as those in my network. I almost always as Michelle, the nurse I practice with, for her opinion and whether I missed anything.
  3. Refer a lot. I practiced for a time with Dr. Bruce King at Lakewood Animal Hospital in Coeur d'Alene, Idaho. Dr. King is scary smart and one of the top veterinarians I've ever met, out of thousands. Yet from Day One I found that he was quick to refer cases for imaging, dentistry, surgery, dermatology and more. He believed it was better that the pet receive the right diagnosis or treatment than have him feel or project that he knew and could do it all.
  4. Rehearsed spontaneity. I proudly tell pet owners that I don't know "for sure" what's wrong with their pet but that I'm going to find out. I'll say something like ,"I have the ZIP code or your pet's illness, but I need to find the address," or "I feel like I have some pieces to this puzzle, but I'm going to get the rest by consulting with my colleagues and doing additional tests."
Here's the truth, hard as it can be for us to accept: "I don't know" can be far more powerful, welcomed and heartening to a pet owner than the tacit "I know it all" attitude projected by some veterinarians. Don't resist it; embrace it!"

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